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Early Reports on Iowa Pharmaceutical Case Management Seem Encouraging

Nancy Tarleton Landis

Pharmacists at 126 pharmacies participating in Iowa Medicaid pharmaceutical case management (PCM) are receiving payment for monitoring the drug therapy of high-risk patients. More than 150 of the state’s roughly 2000 pharmacists have qualified to provide PCM services.

PCM was authorized by the state legislature in 1999 and implemented in October 2000.

The federal Health Care Financing Administration approved PCM services through an amendment to the state Medicaid plan. Researchers from the University of Iowa will measure the clinical and fiscal impacts of PCM and present a final report to the legislature in December 2002.

"We are very excited about the information we’ve gathered about services during the project’s first quarter," said pharmacist Nancy Bowersox, vice president, clinical pharmacy services, at the Iowa Pharmacy Association (IPA). Survey responses from 86% of the participating pharmacies indicated that pharmacists had met with and evaluated more than 30% of the eligible patients.

The Iowa Department of Human Services identified 1561 patients in the project’s first quarter and 540 additional patients in the second quarter. To qualify for PCM services, patients must have at least 1 of 12 diseases, be using at least four regularly scheduled nontopical prescription drugs, and be receiving medications from PCM-eligible pharmacies.

Physician–pharmacist teams may work with patients in their practices who are identified as eligible for PCM services. PCM does not involve collaborative practice agreements but features loosely structured teams consisting of the patient’s usual primary care providers. The pharmacist invites the patient to participate and contacts the physician, and the team decides which services would benefit the patient. Both providers are paid at the same rates: $75 for initial assessment, $40 for new problem assessment, $40 for problem follow-up assessment, and $25 for preventive follow-up assessment.

"We’re thrilled," said Bowersox, that the PCM initiative recognizes pharmacists as individual providers.

Participating pharmacies are required to have private patient consultation areas and problem-oriented, longitudinal patient record systems and to meet other criteria. Eligible pharmacists must be employed at participating pharmacies and present evidence of their ability to provide patient care (see September 15, 2000, AJHP News).

Pharmacies associated with several health systems are participating, said Bowersox, including the Mercy network of pharmacies in the Dubuque and Mason City areas, pharmacies affiliated with the Covenant system in Waterloo, and the John Deere Pharmacy Group in Waterloo.

Survey results indicate that in the program’s first quarter only 11% of patients and 7% of physicians had declined to participate. More frequently, patients identified as eligible were not participating because their circumstances had changed (e.g., they had moved or been admitted to nursing homes) or because of pharmacy staffing issues. At an IPA educational meeting in January, participants exchanged tips on how to overcome barriers to the success of the program.

As PCM entered its second quarter, a preliminary report to the legislature included several success stories (box).

Praise for PCM

  • A middle-aged woman had been taking prednisone for asthma for 10 years, with no preventive therapy for osteoporosis. The pharmacist contacted the patient’s allergist and primary care physician; each physician thought the other was taking care of this. At the pharmacist’s recommendation, the patient was screened for osteoporosis and started on calcium and vitamin D. Both physicians were pleased that the pharmacist coordinated the patient’s care. 
  • A pharmacist reviewed a patient’s blood pressure medication and found no problems, but the pharmacist recommended a more cost-effective medication in the same class. 
  • A pharmacist reviewed the medications of an elderly patient who had been hospitalized for uncontrolled asthma. The patient was not using the correct inhaler for the "rescue" medication and was using improper technique. At follow-up after instruction by the pharmacist, the patient knew what each inhaler was for and in what order the medications should be used. The physician was pleased with the service and asked for more information about PCM. 
  • A pharmacist visited the home of an elderly patient with diabetes mellitus and asked to see her diabetes treatment supplies. The patient was using syringes of the wrong size to draw up insulin, and her blood glucose control was erratic. After providing instruction and the correct syringes, the pharmacist commented that the patient continues to be a challenge but that together they are making small steps toward controlling her diabetes.

Also included was a letter to a pharmacist from a patient that read, in part:

I want to thank you so much for the study you did on my medication. Because you did this and talked to Dr. _______, he did a series of [tests] and found that I have a serious blood problem…. Had it not been for you, we might not have found out about this for some time.